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Overhead Athlete Thoracic Spine and Scapula Assessment and Treatment

Original Editor - Ari Kaplan

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Overhead activities, like throwing or hitting a ball, rely on specific movements occurring at the thoracic spine and scapula. Dysfunction in these regions can have a significant impact on performance, causing pain and affecting throwing and overhead mechanics. Effective management of overhead athletes requires clinicians to understand optimal movement patterns and identify limitations or impairments that affect performance.[1]

Thoracic Spine and Scapular Biomechanical Requirements in Overhead Athletes

"[...] changes in the biomechanics of the thoracic spine and scapula affect the function of the shoulder."[2]

Overhead throwing requires approximately 11-13 degrees of thoracic extension, a posterior tilt of the scapula, as well as upward rotation and slight external rotation of the scapula (though this remains debated).

Without these components, overhead athletes might develop compensatory patterns that increase injury risk and reduce performance efficiency.[3][4] Research also suggests that overhead athletes can also develop thoracic spine and scapula adaptations that enhance their throwing efficiency, such as increased upward rotation, internal rotation, and retraction during arm elevation.[5]

General Principles of the Thoracic Spine and Scapular Assessment in Overhead Athletes

When assessing athletes, the clinical assessment needs to consider the specific demands and context of the athlete's sport, including common injury patterns, sport-related movement asymmetries, compensatory strategies, and potential issues with postural endurance.[6]

Thoracic Spine Assessment

The thoracic spine assessment can include a range of tests and measures. It is important to note, though, that thoracic mobility "has been regarded as difficult to measure objectively and thus [is] highly subjective, leaving clinicians using unreliable instrumentation."[6]

During the thoracic spine evaluation, clinicians should assess the upper, middle, and lower thoracic spine and their interaction with the scapulothoracic articulation.[6] A thorough evaluation will include assessments that integrate upper extremity movements.[4] It is also important to confirm if an athlete has sufficient thoracic extension before assessing thoracic rotation, as hyperkyphosis limits rotation.[4][7]

Movement of the thoracic spine is typically evaluated through visual analysis of active range of motion in sitting (extension, flexion, rotation, side bend/lateral shift), noting pain, movement quality and quantity, compensatory patterns, or asymmetries.[6] Since isolating thoracic extension can be challenging, clinicians may use techniques such as combining a pelvic tilt with a sternal lift manoeuvre to stabilise the lumbar spine. This manoeuvre can be performed in different positions (e.g., in prone, sitting, standing).[6] Digital inclinometers can provide more objective measurements when needed.[8]

Segmental mobility assessment during seated thoracic extension and flexion can help identify hypermobile or hypomobile segments. Clinicians palpate individual spinous processes to feel the available movement at each level and identify compensatory fulcrums above or below a segment—a compensatory fulcrum can indicate hypomobility.[6]

If you would like to read more about the thoracic spine assessment, please see: Assessment and Treatment of the Thoracic Spine.

Scapular Assessment

When assessing the scapula, the following sequence can be useful: (1) postural and resting position, (2) passive range of motion, (3) active range of motion and dyskinesia, and (4) strength testing. This progression ensures that mobility restrictions are identified before strength deficits, providing clear intervention targets.[9]

Resting Position Assessment

Understanding the normal, or ideal, scapular resting position is essential when assessing shoulder function. Ideally, the medial border of the scapula will sit approximately 5-6cm laterally to the thoracic spinous processes when measured at T4. The superior angle of the scapula should align with T2 and the inferior angle with T7. The scapula will ideally sit in the scapular plane (i.e., not fully frontal, but angled slightly forward)—this is equivalent to around 30 degrees of internal rotation. The glenoid should sit in around 5 degrees of upward rotation (i.e., angled slightly upward rather than downward). Finally, the scapula should sit in an anterior tilt of around 10 degrees. This means the inferior angle of the scapula is slightly closer to the rib cage than the superior angle.[9]

Alterations to Scapular Positioning

Specific muscle imbalances can result in altered scapular positioning.

Frontal Plane

In the frontal plane, excessive upward rotation could be due to hypertonicity of the upper trapezius, lower trapezius, or serratus anterior, while a downwardly rotated scapula might be due to overactivity of the rhomboids and levator scapulae.

Scapular elevation could be caused by upper trapezius or levator scapulae hypertonicity, while scapular depression may be due to issues with latissimus dorsi or lower trapezius.

Abduction may be caused by hypertonicity of pectoralis major and minor, while adduction could be related to hypertonicity of the rhomboids or middle trapezius.

Transverse Plane

In the transverse plane, increased internal rotation could be due to pectoralis minor or infraspinatus hypertonicity, while increased external rotation can be caused by subscapularis hypertonicity.

Sagittal Plane

In the sagittal plane, excessive anterior tilt might be caused by pectoralis minor hypertonicity or thoracic kyphosis, while a posterior tilt may be related to thoracic spine issues.

Scapular movement and[10] direction.

Passive Range of Motion Assessment

Assessing passive scapular mobility helps to determine whether restrictions are structural or muscular. Key movements to assess include retraction (adduction), posterior tilt, and upward rotation. The scapular assistance test can also be useful. If passive motion is restricted, strengthening exercises will be less effective until mobility is restored.[9]

Active Range of Motion and Dyskinesia Assessment

"Scapular dyskinesis is defined as an abnormal position or movement of the scapula at rest or during motion, which may include excessive mobility, asymmetry, or scapular winging." [11]

To evaluate for scapular dyskinesia, observe the position/movement of the scapula during shoulder flexion and abduction. Kibler et al.[12] identified four types of scapular dyskinesia:

  • Type I: inferior angle prominence
  • Type II: medial border prominence
  • Type III: early scapular elevation or excessive/insufficient upward rotation during arm elevation
  • Type IV: no pathology is observed[12] [9]

However, current assessment practice simply focuses on whether dyskinesia is present or absent, based on key observations, including winging patterns, movement asymmetry, excessive hiking, inadequate upward rotation, and compensatory upper trapezius overactivation. Testing may require multiple repetitions or adding a weight (3-5 pounds) to elicit fatigue-induced dyskinesia patterns.[13]

The Scapular Dyskinesis Test (SDT) also provides a reliable method to assess for scapular dyskinesis in overhead athletes.[13]

Clinical significance: scapular dyskinesis can indicate underlying muscle imbalances, nerve damage, postural issues, or glenohumeral joint pathology.[14] Correcting scapular dyskinesis through targeted exercises and manual therapy is often a key focus of rehabilitation programmes for different shoulder conditions, including impingement syndrome, rotator cuff tendinopathy, and instability.[9]

Strength Assessment

Strength testing should follow the mobility assessment. Testing typically includes the lower trapezius, middle trapezius, and rhomboids. Handheld dynamometry provides objective measurements, but manual muscle testing remains a suitable method of testing when a dynamometer is unavailable.[9]

Thoracic Spine Mobility Interventions for Overhead Athletes

A range of passive and active interventions can be utilised when thoracic hypomobility is identified, including manual therapy and self-soft tissue mobilisation.[9]

For the mid-thoracic spine mobility restrictions, foam rolling or using a lacrosse ball to massage the erector spinae muscles can be beneficial. These techniques can also be helpful when a person has pain in the thoracic paraspinal/erector spinae muscles. Stretching and exercises like "thread-the-needle", lying supine on a TheraBall, or the "windmill exercise" can also help.

Similar soft tissue techniques can be used for the upper thoracic spine (T1-T3), such as using a lacrosse ball to massage the upper erector spinae, levator scapulae, or upper trapezius. Self-mobilisations on a TheraBall or against a wall may also be useful. Cervical retraction is a simple and effective exercise to counteract the slump position many people adopt during the day. It mobilises the upper thoracic spine and can help to alleviate neck pain and reduce tension in upper neck muscles.

Diaphragmatic breathing may also help to improve thoracic mechanics and reduce compensatory upper chest breathing patterns.

The following optional videos demonstrate the "thread-the-needle" and "windmill exercise":

[15]
[16]

Scapular Interventions for Overhead Athletes

It's important to first address mobility restrictions, focusing on hypertonic areas that may be contributing to suboptimal scapular positioning. Manual and soft tissue techniques can be used, including friction massage, passive joint mobilisation, Maitland techniques, targeted myofascial release, trigger point therapy, and muscle energy techniques.[11]

Motor control retraining can help athletes increase their strength, reduce pain, and enhance scapular kinematics.[11][17][18] Exercises might include: side-lying scapular clocks, side-lying horizontal abduction, side-lying flexion, and side-lying external rotation.[9]

Progressive Strengthening

First, aim to re-establish scapular control and stability before advancing to more challenging strengthening. Starting with side-lying exercises (horizontal abduction, flexion, and external rotation) minimises gravitational resistance and facilitates muscle activation. During this phase, the focus should be on the quality of movement over quantity. This ensures proper movement patterns are established.[9]

Once basic control and pain-free movement are achieved in a side-lying position, progress speed and positional complexity. For example, prone exercises and standing TheraBand exercises can be introduced. Other progressions include sport-specific positioning, plyometric training, and speed progressions. All progressions must be tailored to the athlete's goals and the demands of the sport.[9]

Neuromuscular Reeducation Techniques

Rehabilitation for overhead athletes can also include neuromuscular control techniques, like rhythmic stabilisation, reactive drills, plyometrics, muscle energy techniques, and proprioceptive neuromuscular facilitation (PNF).[19] Muscle energy techniques help to improve joint positioning and muscle length. PNF exercises can be especially helpful because they enhance scapular movement patterns.[9]

Conclusion

This approach to the thoracic spine and scapular assessment helps to ensure targeted treatments. Clinicians must differentiate between primary and secondary issues, recognising that pain location may not indicate the primary dysfunction. A systematic progression through each level of assessment ensures that underlying mobility restrictions are resolved before advancing to strength and functional training phases.

Resources

References

  1. ↑ Kibler WB, Sciascia AD, Grantham WJ. The shoulder joint complex in the throwing motion. J Shoulder Elbow Surg. 2024 Feb;33(2):443-449.
  2. ↑ Choi M, Chung J. Biomechanical and functional analysis of the shoulder complex and thoracic spine in patients with subacromial impingement syndrome: A case control study. Medicine (Baltimore). 2023 Jan 27;102(4):e32760.
  3. ↑ Forthomme B, Crielaard JM, Croisier JL. Scapular positioning in athletes' shoulders: particularities, clinical measurements and implications. Sports Med. 2008;38(5):369-86.
  4. ↑ 4.0 4.1 4.2 Howe L, Read P. Thoracic spine function: assessment and self-management. Professional Strength & Conditioning 2015;39:21-30.
  5. ↑ Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Scapular position and orientation in throwing athletes. Am J Sports Med. 2005 Feb;33(2):263-71.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Ruiz J, Feigenbaum L, Best TM. The Thoracic Spine in the Overhead Athlete. Curr Sports Med Rep. 2020 Jan;19(1):11-16.
  7. ↑ Manoso-Hernando D, Bailón-Cerezo J, Elizagaray-García I, Achútegui-García-Matres P, Suárez-Díez G, Gil-Martínez A. Cervical and Thoracic Spine Mobility in Rotator Cuff Related Shoulder Pain: A Comparative Analysis with Asymptomatic Controls. J Funct Morphol Kinesiol. 2024 Jul 24;9(3):128.
  8. ↑ Bucke J, Spencer S, Fawcett L, Sonvico L, Rushton A, Heneghan NR. Validity of the Digital Inclinometer and iPhone When Measuring Thoracic Spine Rotation. J Athl Train. 2017 Sep;52(9):820-825.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Kaplan A. Overhead Athlete Scapula and Thoracic Assessment and Treatment. Plus Course 2025
  10. ↑ Seitz AL, McClure PW, Finucane S, Ketchum JM, Walsworth MK, Boardman ND, Michener LA. The scapular assistance test results in changes in scapular position and subacromial space but not rotator cuff strength in subacromial impingement. J Orthop Sports Phys Ther. 2012 May;42(5):400-12.
  11. ↑ 11.0 11.1 11.2 Wen M, Hu X, Bao G. Scapular dyskinesis-based exercise therapy versus multimodal physical therapy for subacromial impingement syndrome in young overhead athletes with scapular dyskinesis: a randomised controlled trial. BMC Sports Sci Med Rehabil. 2025 Jul 16;17(1):204.
  12. ↑ 12.0 12.1 Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability study. Journal of shoulder and elbow surgery. 2002 Nov 1;11(6):550-6.
  13. ↑ 13.0 13.1 McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular dyskinesis, part 1: reliability. J Athl Train. 2009 Mar-Apr;44(2):160-4.
  14. ↑ Kibler WB, Sciascia A. Current concepts: scapular dyskinesis. Br J Sports Med. 2010 Apr;44(5):300-5.
  15. ↑ Six Physio. Threading the needle - a thoracic spine stretch. Available from: https://www.youtube.com/watch?MfUx9FCOb1E [last accessed 29/8/2025]
  16. ↑ Body Basics. Standing Windmill Exercise. Available from: https://www.youtube.com/watch?a-KqiYR7CZc [last accessed 29/8/2025]
  17. ↑ Moradi M, Hadadnezhad M, Letafatkar A, Thomas AC, Hosseinzadeh M. Effect of motor control retraining program on symptoms, strength, and function in individuals with shoulder impingement syndrome and scapular Dyskinesis: a randomized controlled trial. J Bodyw Mov Ther. 2025 Sep;43:201-209.
  18. ↑ Melo ASC, Soares AL, Castro C, Matias R, Cruz EB, Vilas-Boas JP, Sousa ASP. Shoulder and scapular function before and after a scapular therapeutic exercise program for chronic shoulder pain and scapular dyskinesis: a pre-post single-group study. J Pers Med. 2025 Jul 2;15(7):285.
  19. ↑ Reinold MM, Gill TJ, Wilk KE, Andrews JR. Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 2: injury prevention and treatment. Sports Health. 2010 Mar;2(2):101-15.
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